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Summary Statement

An in-depth discussion of skin protection, including recognition of skin problems, causes, the science behind them and methods to protect against them, focused on the employer. Part of a collection. Click on the 'collection' button to access the other items.
2000

This
material is supported in part with funds from the National Institute for
Occupational Safety and Health (NIOSH) through CPWR – Center for Construction Research and Training to a consortium of CPWR, the Operative Plasterers & Cement
Masons International Association, and FOF Communications. Researched,
developed, and produced by FOF Communications.

The
material does not necessarily reflect the views or policies of NIOSH.
Mention of trade names, commercial products or organizations does not
imply endorsement by NIOSH, the U.S. Government, CPWR, OPCMIA, or FOF
Communications.

The
Occupational Safety and Health Act of 1970 makes the employer responsible
for providing a safe and healthful workplace that is free of recognized
hazards.

If your
employees work with wet cement products—concrete, mortar, plaster,
grout, stucco, or terrazzo, this handbook is for you. It will help you
prevent employee skin problems from cement.

Development of this handbook was supported by the National Institute for
Occupational Safety and Health/CPWR Consortium on Preventing Contact Dermatitis.
Consortium partners are CPWR – Center for Construction Research and Training, the
Operative Plasterers & Cement Masons International Association, and
FOF Communications. The handbook was researched, developed, and produced
by FOF Communications.

The consortium has been instrumental in focusing the cement industry on
skin problems and in disseminating innovative protective measures such
as the use of neutralizing agents.

The consortium supported a Physician Alert brochure to help cement
products workers talk with their doctors; the Save Your Skin booklet
on glove wear; a Safety & Health Practitioner’s Guide;
a Tool Box Pamphlet; a worker classroom training program; a training
evaluation study; jobsite visits for pH testing of surface skin and rinse
water; a stakeholder symposium, and a professional advisory group meeting
on the development of this handbook. To learn more, visit NIOSH at http://www.cdc.gov/niosh/topics/skin/occderm-slides/ocderm.html
or CPWR at www.cpwr.com
or call the NIOSH Technical Information Branch (800-356-4674) or CPWR
(301-578-8500).

CHAPTER
1

Recognizing Skin Problems

Ted Jason’s
eight-year old daughter got a painful rash that would not go away. The
Jasons took her to several doctors. They applied ointments. They washed
her sore skin with prescribed soaps. Nothing they did made a difference.

Then Ted took a course on preventing dermatitis from cement. He learned
to measure the pH of the surfaces of his boots and his car interior.

Ted found out that
alkaline cement dust from his work had contaminated his life in a way
he had never before appreciated. He realized his daughter had been exposed.

So Ted began following
the tips given in the course. He cleaned his car interior and began removing
his work clothes before getting into it. He switched to pH-neutral soap
for his daughter. Within a few weeks, her skin problem was gone—and
so was his.

WHY WORRY ABOUT
CEMENT?

Ted Jason’s
problems are not uncommon. Maybe you have a skin problem from cement or
know someone who does. Portland cement is estimated to account for 25%
or more of all work-related skin problems worldwide.
11

Reported lost work
days for skin problems in US masonry trades are 2.5 times the national
average. Concrete workers lose time at 7 times the average. Concrete workers
report 4 times more lost work days for skin problems than do all construction
workers.
24

Most experts agree that
reported lost time is just the small tip of a very large iceberg of disease.
So a statistically reliable survey 15 of apprentice cement masons was especially
alarming.

71% of apprentices
hadone or more skin problems. Only 29% reported no skin problems.

A surprising 71% of apprentices reported one or more skin problems. Only
29% reported no skin problems. The apprentices averaged only 3.3 years of
experience in the trade.

Only 7%
reported lost time or doctor visits for skin problems.

Only 7% of those with skin problems reported lost time or doctor visits
for their problems. 93% of the apprentices with skin problems continued
to work without seeking medical treatment—setting themselves up for
lifelong health problems.

Four types of
skin problems happen most often among cement products workers:

Irritation
or dry skin (mild ICD)

Irritant contact
dermatitis (ICD)

Allergic contact
dermatitis (ACD)

Caustic burns
(cement burns or chemical burns)

There
are different ways to get a long-lasting skin problem. There is no single
pattern. You cannot predict who will get skin problems based on experience
or on medical tests.

Dry skin
(mild ICD) may include scaling, itchiness, burning, redness.
Dry skin may be called xerosis. An employee’s cement exposure can
lead directly to dry skin or irritation.

Allergic
contact dermatitis (ACD) is an immune response. It is like other
allergies but it involves the skin. ACD includes many symptoms of ICD.
ACD is difficult to cure. The allergy may last a lifetime. Cement exposure
can lead directly to ACD. This can happen without any warnings, such
as local irritation.

Caustic
burns (cement burns) are alkali burns. They should be referred
to a medical specialist without delay. By the time an employee becomes
aware of a burn, much damage has been done and further damage is difficult
to stop. Cement burns look like other burns. They produce blisters,
dead or hardened skin, or black or green skin. Cement burns also can
lead to allergic dermatitis.

WHAT DO SKIN PROBLEMS
COST?

Each year occupationally-related skin problems affect one American worker
in a thousand. No one knows how many family members are affected by contaminants
brought home from the job. Skin problems are the second most common work-related
disorder in the US, surpassed only by ergonomic problems. Reported skin
diseases are about 15 to 20% of all work-related disease.
25

What
do occupational skin problems cost the US economy each year?

Estimated costs
for medical care, lost production, and disability payments for reported
skin disorders total up to $1 billion a year, according to NIOSH.

The costs to employers
include worker compensation disability claims, lower productivity, and
poor morale. The costs to workers include reduced earnings, medical bills,
loss of a trade, social disability, embarrassment, and lower quality of
life.

The rates of most
other occupational injuries and disease have fallen. But skin disease
rates have increased. Little progress is made, even though the causes
are better understood and more methods of control exist now than ever
before.

‘DERMATITIS
WON’T KILL YOU’

A nameless industry
leader said this not long ago before a training class on preventing contact
dermatitis.

It may be true—although
some workers with disfiguring cement burns or rampant chrome allergy dermatitis
might wish it would.

Skin problems from
cement are widespread and, unfortunately, they are too often tolerated
as part of the price of work in some trades.

Our tolerance permits
the high rates of occupational skin problems in the United States to continue.

But put yourself
in the place of a worker with a persistent skin problem. If your hands
or other skin are covered with rashes, irritation, or sores, it can make
you less socially acceptable as well.

Many male cement
products workers have said their wives or girlfriends do not appreciate
their skin problems. Young single men and women with occupational skin
problems often feel at a disadvantage when socializing. Whether the cement
products worker goes to a school conference and shakes the teacher’s
hand, goes to a bank and shakes the loan officer’s hand, or goes
to a broker to make an investment—in every aspect of American life,
an occupational skin problem can make the individual feel less than comfortable.

Social disadvantages
do not take into account physical pain and suffering, the loss of morale,
the loss of income, or the loss of personal leisure time devoted to grappling
with an ongoing health problem.

As a conscientious
employer, you have many motives for caring about your employees’
skin. Some of them are financial. Some of them involve productivity.

Some
of every employer’s motivation
should come from concern
for employee quality of life.

WHAT
CAUSES SKIN PROBLEMS?

Skin
may be affected by one or more of the following factors:

worksite materials,

worksite conditions,

environmental
factors, and

individual factors.

The skin is the single
largest organ. It covers 20 square feet of surface. The skin's purpose
is to protect the body from outside substances, chemicals, and bacteria.

Skin has two layers.
Together both are less than 1/8-inch thick.

The epidermis
(outer layer) is only 1/250th of an inch thick.

The dermis is
only 1/50th to 3/25ths of an inch thick.

The skin contains
oil glands, hair follicles, and sweat glands—all are like tiny holes.
So the skin can be like a leaky roof or a sponge when it contacts chemicals.
Skin also contains blood vessels. Some chemicals can penetrate the skin
and enter the bloodstream.

Normal surface skin
is moderately acidic. Recent research has shown that this ‘acid mantle’is
necessary to allow the skin to repair itself after an external ‘insult.’An
alkaline pH impedes repair.

Worksite materials
can cause skin problems. Some materials ‘insult’ and injure
skin. Some pass through it into the bloodstream.

Portland cement
is very alkaline (caustic) when wet so it affects skin surface
pH. Cement is hygroscopic so it draws moisture from skin.

Cement products
are abrasive and physically damage the skin surface, making it
a less effective barrier against chemicals. The moisture in eyes, mucous,
and sweaty or damp skin can activate dry cement, making it caustic.
These factors allow cement to cause dry skin and irritant contact dermatitis.

Sensitizers
in workplace materials may cause an allergic response. The reaction
may be local or widespread. Sensitization is an immune response. The
immune system fights a foreign substance. Usually, the material causes
no change on first contact. Once a person is sensitized, small amounts
can trigger a strong reaction. Many people cannot tolerate further exposure.

Hexavalent chromium(Cr6+) is a sensitizer. It is an important cause of
allergic contact dermatitis. Cement’s alkalinity increases skin
absorption of this soluble chromate. Some studies show that Cr6+
penetrates the skin and enters the bloodstream.

Worksite cleaners
too often are caustic and abrasive. They also may contain sensitizers
like lanolin, limonene, or perfume and irritants like alcohol.

Is there mechanical
trauma or abrasion of the skin (a break in the barrier)?

Is the material
trapped or occluded to the skin with gloves, creams, lotions, petroleum
jelly, or barrier creams?

Are there adequate
hygiene facilities?

Environmental factors can cause skin problems directly or they can
workwith other factors to increase skin problems:

Heat causes
sweating. Sweat dissolves chemicals and brings them into closer contact
with the skin. Heat increases blood flow at the skin surface and increases
absorption of materials into and through the skin.

Cold dries
the skin and causes microscopic cracks. Cold changes blood flow at the
skin surface and leads to loss of feeling.

More than 92.7 million
metric tons of cement were consumed in US construction in one recent
year, according to the Portland Cement Association . Cement consumption
has increased every year since 1991.
21

Cement is a mixture
of lime, silicates, aluminum, iron, magnesium, and other additives such
as gypsum, fly ash, and blast furnaceslag.
1
Cement is a component in:

tile grout—a
fluid mortar mixture consisting of Portland cement and water with or
without aggregate, and

other products.

Portland Cement
Products Workers

More than 1,300,000
American workers in 30 occupations are regularly exposed to wet cement.

The families of these workers may be exposed to cement dust on their work
clothes.

Following is a partial
list of the construction trades workers who may be regularly exposed to
cement:

bricklayer,

carpenter,

cement mason
or concrete finisher,

concrete truck
driver,

construction
craft laborer,

hod carrier,

plasterer,

terrazzo worker,

tile setter,
and

others.

Portland Cement
Work Tasks

Below are some of
the work tasks that expose construction workers to Portland cement:

tending concrete pour,

mixing and spreading
grout,

preparing cement
underlayer for terrazzo,

hosing out ready
mixed concrete truck, mixer, and chute,

using mortar
to set brick, block, and other masonry,

dismantling formwork
contaminated by Portland cement,

pouring, leveling,
smoothing, and finishing concrete,

attaching tiles
to walls, floors, and ceilings,

mixing mortar
and providing it to other craftsworkers,

mixing and applying
plaster, stucco, and EIFS, and

spraying Portland
cement products such as fireproofing, gunite, or shotcrete.

The Nature of
Cement

Cement has many properties
which are damaging to skin. Cement is alkaline, or caustic. The pH of
wet cement ranges from 12 to 13. Cement is hygroscopic, pulling moisture
from the skin. Cement is abrasive. Cement may contain sensitizing chemicals
and metals, such as hexavalent chromium (Cr6+).

The composition of
cement varies somewhat from region to region. However, the alkaline, abrasive,
and hygroscopic properties of cement in concrete, mortar, grout, plaster,
stucco, and other products are universal.

Perhaps most frequently
damaging of all these properties is the alkaline pH.

CHAPTER
3

Normalizing pH

Wet cement is an
alkali, or caustic. A caustic is any strongly alkaline material with a
corrosive or irritating effect on living tissue. Alkalinity is essential
in the development of irritant contact dermatitis (ICD) from cement.
4

pH is a measure of
the alkalinity or acidity of a material. Pure water has a pH of 7 and
pH 7 is considered pH-neutral.

Strong alkalies are
pH 12 to 14. Cement is extremely alkaline, or caustic, with a pH value
of 12 to 13. Strong acids are pH 1 to 3.

pH represents the
acidity or alkalinity of a watery solution on a scale. The pH scale is
like the Richter scale for earthquakes. Both are logarithmic. On
a logarithmic scale, the intervals between numbers are not equal. Rather,
each number may be many times greater or smaller than the previous number.

pH
13 is one million times more alkaline than pure water at pH 7. pH
1 is one million times more acidic than pure water. What is the pH
of an orange? An organe has a 3.5 pH level.

One
of the authors tests surface skin pH of a cement products worker.
Even though this worker and others wore gloves, their skin surfaces
tested at pH 9 to 12, the same range as those workers who wore no
gloves.

Wearing gloves
without good hygiene practices appears to be no more protective than
no gloves at all.4 Neutralizing alkaline cement requires
clean running water and pH-neutral or acidic soap.19 It may be helpful
to use a buffering solution to normalize surface skin pH.9

pH Values

Like the earthquake
scale, the pH scale is logarithmic. So the intervals between numbers are
not equal.

Every whole number is a 10-fold change in alkalinity or acidity.

An
orange is pH 3.5, like vinegar.

Healthy skin
is 4.5.

Acidic pH is
<7 to <1.

Pure water
is pH 7.

Alkaline or
caustic pH is >7 to 14.

Cement is
up to 1,000,000,000 times more alkaline than human skin.
pH 13 is 1,000,000 times more alkaline than pH 7.

Acids ionize in water
to give H
+
(hydrogen) ions. Alkalies (bases) produce OH - (hydroxyl group) ions in
water. You can learn more about the technical chemistry of pH by looking
in a chemical dictionary or a chemistry textbook.

The pH Of Healthy
Skin

Normal skin is pH
4.5 to 5.5, meaning it is moderately acidic. The acidic pH of skin has
been recognized for a century. However, the purpose of the ‘acid
mantle’ of skin is not completely understood. Scientists believe
it has to do with processing of lipids (fats) required for skin barrier
function. Contact with wet cement changes skin pH to alkaline. At alkaline
pH, skin barrier repair is slowed, damage is prolonged, and skin problems
are worsened.

The slightly acidic
pH of normal skin also helps it to resist bacterial infection. Bacteria
don’t like acidic environments. In fact, meat inspectors test pH
as a measure of freshness. When the pH of meat becomes slightly alkaline,
bacteria are more likely to multiply.

Further, alkalinity
contributes greatly to skin absorption of the hexavalent chromium (Cr6+)
in cement.3 So a cement worker’s absorption of Cr6+ can
be greatly increased when it contacts skin in cement.

Acids

Acids are a large class of chemicals with pH values ranging from less
than 7 to less than 1. Acids with pH 1 are one million times more acidic
than pure water.

Strong alkalies can
be more dangerous because they damage skin slowly without immediate pain.
An alkali can remain on skin for hours before a burn is felt.

Weaker acids include
vinegar and citric acid (oranges).

When an acid is added
to an alkali, it tends to neutralize the pH. For example, if you add vinegar
to cement water, it can reduce the pH from 12 to 8. You can do this experiment
with small amounts of cement water and vinegar using the pH indicator
papers pictured below. (The reaction of acids and alkalies together can
release heat.)

Buffers

A buffer is a substance
that can neutralize either an acid or an alkali. A buffer may be a mixture
of a weak acid and a salt of that acid that is intended to maintain a
desired pH. Phosphates are often used as buffering agents.

In addition to eliminating
the caustic effect of cement, neutralizing pH may convert hexavalent chromium
(Cr6+) to trivalent (Cr3+), reducing the risk of
ACD.

pH Indicators

pH indicator papers, like those below, make it easy to get reasonably
accurate measurement of pH on skin surfaces, car interior surfaces, and
other places. To test skin or dry surfaces, moisten the indicator in distilled
water. Then apply it to the test surface. To test a liquid, dip the indicator
in the liquid. Full range indicator papers (pH 1 to 14) work best for
cement.

A pH test meter, shown below, can be used to test rinse bucket pH. However,
cement particles in the water can clog this instrument. Paper test indicators
are probably more reliable for that reason.

pH-Neutral and
Acidic Soaps

Caustics like wet
cement can dry and irritate the skin. But did you know the soaps your
employees use for cleanup at work and at home could make the problem worse?
Many well-known soaps and cleaners are caustic. These soaps or cleaners
can add to the dryness and irritation caused by the caustics used at work.

Your employees may
be better off with a soap that is pH-neutral or slightly acidic. These
soaps are closer to the pH of healthy skin. They also help “neutralize”
the effect of worksite caustics.

For best results
in selecting the right soap, the worker should consult a doctor.

To help select appropriate
soaps, we tested the pH of some popular brands. We also checked the ingredients
listed on the MSDSs.

The chart lists pH
values for 39 soaps and cleaners.

pH-neutral and slightly
acidic soaps and cleaners are good bets.

Bar Soaps

pH Value

Basis

9

Caress

7

Clearly Natural

9

Coast

9

Dial

10

Dove

6

Grandma's Oatmeal

10

Irish Spring

10

Ivory

10

Jergens

10

Kiss My Face

11

Lava

9

Lever 2000

9

Neutrogena

9

Oil of Olay

7

Palmolive

10

Safeguard

9

Shield

9

Tom's of Maine

10

Tone

10

Vermont Country

9

Yardley

10

Zest

10

Liquid
Soaps

pH
Value

Aloe
Vera 40

6

Cetaphil

6

Dial

6

Dove

6

Gillette
Wash

6

Gojo
Orange

5

Gojo
Cream

8

Ivory

6

Jergens

6

Joy

6

Lever
2000

6

Neutrogena
Rainbath

6

Noxema

7

Palmolive

7

pHisoderm

5

Softsoap

6

In
addition to these factors, consider possible allergies and other potential
problems. Watch the skin’s reaction to a new soap. Read the label.
Call the manufacturer and get an MSDS. Discuss all skin conditions
with your physician.

Don’t
be fooled by advertising. Many soaps may promote themselves as ‘gentle,’
‘natural,’ or ‘pure.’ But they are actually caustic.
This may be fine for people who do not work daily with alkalies or
caustics. But it may be irritating to the skin of workers who use
cement.

pH-neutral is 7.
Soaps with pH below 7 are more acidic—like citrus or vinegar. Soaps
above pH 7 are more caustic—like cement.

Regardless of pH,
any soap containing lanolin, limonene, or perfume probably should be avoided
if you are sensitive to those ingredients.

The chart is advisory
only. To obtain reliable information, ask your pharmacist or ask the soap
manufacturer for an MSDS. The authors do not endorse any products or claim
the list to be accurate or complete.

CHAPTER
4

Modify Cement at the Plant?

As industry leaders
learn about skin problems, they often ask whether cement can be modified
to reduce the hazards. Different modifications are proposed depending
on the specific skin problem. Remember, cement causes two main problems:
irritant contact dermatitis (ICD) and allergic contact dermatitis (ACD).
Cement causes ICD because it is alkaline, hygroscopic, and abrasive. Cement
causes ACD because it contains sensitizers, mainly hexavalent chromium
(Cr6+).

Neutralize pH?

Some in the industry
have asked that manufacturers reduce the alkalinity of cement. By nature,
wet cement is pH 12 to 13. It will always be alkaline. Attempts to neutralize
the pH of cement would chemically alter it and possibly invalidate its
specified integrity. Upholding the structural integrity of cement and
concrete is paramount. Rather than attempt to neutralize the pH of an
entire batch of cement at the plant, it seems more practical to neutralize
the pH of the small amount of cement that may contact the surface skin
of cement products workers at the jobsite. This can be done with a neutralizing
solution.

Reduce Hexavalent
Chromium?

When ferrous (iron)
sulfate is combined with hexavalent chromium in cement, it forms
an insoluble trivalent compound when water is added.

Trivalent chromium
(Cr 3+ ) is not easily absorbed by skin. Finnish, Danish, and Swedish
scientists have published studies showing that this way of modifying cement
at the plant—as required by legislation in those countries—greatly
reduced ACD in cement products workers.
20
ACD from cement is a common occupational dermatitis among construction
workers and a reduction in the chromate content of cement would be a reasonable
preventive measure.
2,3

American cement makers
experimented with iron sulfate but could not duplicate the Scandinavian
results for several reasons.

First, more than
120 plants make US cement and the product ships long distances in this
country. If iron sulfate is added, the time it takes to transport the
cement may result in spontaneous oxidation of the ferrous ion to the ferric
form, rendering the iron sulfate inactive.

Second, the addition
of iron sulfate during grinding is a patented process. Royalties and the
cost of iron sulfate as an additive (variously estimated at $.05 to $1.00
per ton) would increase the cost of cement products. Added costs may be
incurred in reconfiguring manufacturing processes to allow for the addition
of iron sulfate.

As an alternative,
some researchers have recommended that iron sulfate be added during mixing
of concrete or when delivering premixed cement products to the worksite.
8,12

Finally, cement products
may be modified in another way to reduce Cr6+ levels. Slag
can be substituted for clinker at the plant.
11

American manufacturers
express concern about possible effects of such methods on the structural
integrity of finished concrete. For example, some argue that addition
of substantial amounts of iron sulfate to concrete might cause durability
problems or necessitate adjustment of the amount of gypsum added. (Concrete
in Scandinavia and Singapore appears unaffected by modifications to cement
in those countries.) Manufacturers point out that American specifications
for concrete are rigid, that any changes must be well researched, and
that research is ongoing. So change may be possible some day.

CHAPTER
5

Best Protective Practices

Protecting skin is
not simply a matter of wearing gloves. Alarge percentage of cement products
workers already wear gloves. But, to be effective, glove wear must go
hand-in-hand with proper hygiene. Hygienic practices and use of the correct
gloves will prevent contact with cement. Glove wear without hygiene practices
is no more protective than no gloves at all.
4
In fact, it can make problems worse.

This chapter presents
the best protective practices for preventing skin problems from
cement.

Best practices
at home.

Best practices
at work.

Best practices
in emergencies.

The Best Practices
Checklist.

Not everyone can
do all these practices. But your employees should do as many as possible,
beginning with the easiest ones. There is no guarantee that any or all
of these practices will prevent skin problems from cement. But these practices
are recommended by experts and they represent the best protections known.

What are your
company’s best practices for preventing dermatitis? Before you read
this chapter, take a few minutes to list them on a separate piece of paper.

BEST PROTECTIVE
PRACTICES AT HOME

Tell Employees About pH-Neutral Soaps

Recommend to your
employees that they wash with pH-neutral or acidic soaps. A pharmacy
can identify one.

Remember the discussion
about neutralizing caustics?

Cement products workers
who wash with alkaline soaps unknowingly continue to ‘insult’
their skin with alkalies. During the day they are exposed to caustic cement.
At home they are exposed to caustic soap.

If cement products
workers wash with pH-neutral or acidic soaps at home, it may help restore
the desired pH balance of the skin surface. This allows skin barrier repair
to proceed. If skin remains at an alkaline pH, skin barrier repair is
impeded.

Recommend Separate Laundering Of Work Clothes

Employees should
change out of work clothes at work. Work clothes can be brought home in
a separate container. A trash bag works great. This practice keeps cement
out of the car or truck interior.

Launder work clothes
separately to protect family or roommates. For extra safety, run washer
empty after laundering work clothes.

(Remember Ted Jason’s daughter?)

Dry
Skin or Irritation (Mild ICD). When cement becomes wet, liberated
calcium hydroxide increases the pH in the alkaline direction. Wet
cement has a pH value 12 to 13. This is one billion times more alkaline
than skin. The result may be dry skin or mild irritant contact dermatitis.

Irritant
Contact Dermatitis. Alkalinity is essential in the development
of irritant contact dermatitis (ICD) from cement. At alkaline pH,
human skin is more permeable to many hazards. As the skin's barrier
layer becomes more permeable, repeated contact with abrasive materials
also may contribute to ICD.

Allergic
Contact Dermatitis. Most cement contains metals or other chemicals
which are sensitizers, or allergens. Foremost among them is hexavalent
chromium (Cr6+). Others may be present in admixtures: accelerators,
water reducers, superplasticizers, retardants, air entraining agents,
or polymer-modified systems.

‘Cement
burns.' The occurrence of alkali burns from cement is well documented.
No official data exist on the annual number of cases. A statistically
valid survey 15 found cement burns among 35% of apprentice cement
masons. In severe cases, these burns can cause scarring, even disability.

ICD due
to alkaline soap. Alkaline soaps can cause dermatitis even in
the absence of other exposures. Alkaline soaps can worsen skin problems
caused by cement and are not recommended for cement products workers.

Allergic
Dermatitis Due to Lanolin. Some individuals may develop a sensitivity
to lanolin. Cement products workers should avoid lanolin-containing
products at the worksite because lanolin can occlude cement residue
to the skin. Lanolin-containing products should be applied only to
clean, dry skin in a clean environment.

BEST PROTECTIVE
PRACTICES AT WORK

Each Employee
Needs At Least 5 To 7 Gallons of Clean Running Water Per Day

Bring clean running
water to the jobsite. Employees need clean water for washing before work,
whenever they break, and at the end of the shift. Prohibit cleaning with
abrasive solvent containing
products. These include waterless hand cleaners like the alcohol-based
gels or citrus cleaners. Such cleaners are not suitable for cement
exposure.

Consider providing buffering spray to reduce the pH of any cement residue
on the skin.

Require Employees
To Wash Hands Before Putting On Gloves

Employees should
wash with pH-neutral soap and clean running water, as recommended by the
Portland Cement Association’s sample MSDS.

Dry Hands

Workers should dry
hands thoroughly with a clean cloth or paper towel before putting on gloves.

Wash Hands Again
If Gloves Are Removed

If employees remove
gloves during work, they
must wash again with clean water and pH-neutral or acidic soap. If not,
cement residue will enter the gloves. Don’t allow employees to rinse
their hands in tool rinse buckets.

Long Sleeves Buttoned
Or Taped Inside Gloves

Many experts recommend
wearing long sleeves and taping them inside gauntlet gloves. But if the
sleeves become saturated with wet cement, they must be removed immediately.

Rubber Boots With
Pants Taped Inside

Rubber boots
prevent contact with cement. When pants are taped inside, cement will
not enter the boots. Wet cement inside boots is a common event leading
to severe and possibly disabling cement burns. Cement masons or concrete
finishers should use kneepads and knee boards if they kneel on wet concrete.

Never Let Cement
Remain On Skin Or Clothes

When wet cement gets
on permeable clothing, it must be removed immediately. When wet cement
gets on skin, it must be washed with clean water and pH-neutral or acidic
soap. At the least, consider providing a buffering solution to neutralize
the pH of cement residue.

Provide Or Require
Proper Gloves

Consult a glove manufacturer
to select the right glove for the hazard. Manufacturers often recommend
butyl gloves or nitrile gloves for caustics like cement. Cotton or leather
gloves may become saturated with wet cement. Make sure gloves fit. Loose
gloves let cement in.

Prohibit Barrier
Creams

Barrier creams or
‘invisible gloves’ are not recommended for cement work.
19
The abrasive cement probably breaks the seal of the barrier cream. Also,
reapplying the cream in the work area may occlude or seal cement to the
skin.

Provide Glove
Liners

Glove liners of thin
cotton help make gloves more comfortable. They can help keep hands clean
and dry. But they must not be contaminated with cement inside the gloves.
The goal is to keep the insides of the gloves clean.

Throw Out Grossly
Contaminated Gloves

Gloves should be
cleaned every day before and after removal. Sometimes gloves get so contaminated
they cannot be cleaned. Throw them out.

Disposable gloves
can make it easier for employees to keep their hands clean. Disposable
gloves can be less expensive than reusable gloves.

The only
drawback to disposable gloves is that workers sometimes wear them day
after day.

To remove disposable gloves, peel back from the top, turning them inside
out.

Discard disposable
gloves at the jobsite each day.

Teach Employees
How To Remove Gloves

Before removing
gloves, always clean off the outsides.

Follow the
manufacture's instructions. Watch for pinholes which can let in
contaminated rinse water.

To remove gloves,
loosen them on both hands. Hold hands down so contaminated water
will not drip onto skin or clothing.

Remove
the first glove only to the fingers.

The cuff of
the glove will remain over the palm.

Now, grabbing
the second glove with the first glove, remove the second glove.

The first glove
should slip off.

Try to handle
gloves by the insides only.

Don’t
touch the outsides.

No Jewelry at
Work

Cement
can collect under rings, watches, or necklaces. Wet cement trapped
against skin for long periods is hazardous.

Encourage Employees
To Change Work Clothes At Work

Removing work clothes
at work cuts cement exposure for employees and their family members. It
keeps cement out of the car or truck interior. If work clothes cannot
be left at the job, they should be taken home in a separate container.
A trash bag works great.

Instruct
Employees to Avoid Lanolin, Petroleum Jelly, and Other Skin Softening
Products at Work

Skin-softening products
can occlude or seal cement to skin, can increase the skin’s
ability to absorb contaminants, or can irritate the skin.

Never use petroleum
jelly or other emollients to treat cement burns. Applying such products
can intensify burns by trapping the cement against the skin.

Skin-softening products
should be applied only to clean skin in clean environments. A cement products
worker may use these products, if desired, at home after showering or
bathing with pH-neutral or slightly acidic soap.

But be careful. Some
skin-softening products may contain fragrances, lanolin, or other chemicals
that can cause ACD in susceptible workers.

Urge Employees
To See A Physician

Any employee with
a persistent skin problem, even a minor one, should see a doctor. A statistically
valid survey of apprentice cement masons showed only 7% of those with
skin problems saw doctors even though 71% had had problems in the last
year.15 Some did not think the problems were serious. Others were afraid
of losing employment.

To get effective
treatment, the cement products worker must inform the doctor about products
used at work. The goal is to provide medical treatment for a health problem.

The question of covering
the treatment under worker compensation or a health & welfare plan
is not a topic of this handbook.

A Physician Alert
brochure is available from CPWR – Center for Construction Research and Training
(301-578-8500). The brochure can be given by a worker to a doctor. The
brochure helps explain the skin hazards of cement work.

Ideally, employers and unions can work together to find a way for employees
to see doctors about skin problems before they become chronic and untreatable.

The “Physician Alert” tips can help employees and physicians
talk. So can a product Material Safety Data Sheet (MSDS).

Encourage employees
to follow the doctor’s prescriptions and recommendations. That action,
combined with other best practices, can lead to the successful control
of most cement-related skin problems.

Follow A Model
MSDS

Find the best Material
Safety Data Sheet in the industry and follow its recommendations. The
best MSDS is the one that is most complete and provides the most protective
recommendations.

The Portland Cement
Association (PCA) has published a sample MSDS report.19 It
includes a few of the best practices recommended by experts.

Remember, this MSDS is only the minimum guideline. With a little creative
thought and not too much effort, you can do a lot more for your employees.

BEST PRACTICES IN
EMERGENCIES

Dusty clothing
or clothing wet with cement fluids should be removed promptly and laundered
separately before reuse.

Employees must wash wet cement from the skin with clean water and pH-neutral
or slightly acidic soap.

Employees cannot rely on pain or discomfort to alert them to a hazardous
skin exposure.

Cement Burns

An acid will burn
skin immediately. Cement is sneakier. An employee can work with wet cement
on the skin for hours without feeling any discomfort. But the alkaline
burn of the cement is damaging the skin microscopically. That damage may
be just a cement burn or it also may be the cumulative injury that leads
to irritant or allergic dermatitis.

Cement burns (caustic
burns) are alkali burns. Cement burns progress. This means they get worse
even without more exposure. Anyone who feels a cement burn starting should
go immediately for emergency treatment in an ER or by a burn specialist.
Don’t assume the burn will not get worse. By the time an employee
becomes aware of a burn, much damage has already been done and further
damage is difficult to stop.

Medical experts recommend
flushing the skin with lots of clean water. Some suggest adding vinegar,
citrus, or a buffer to the water to help neutralize the caustic effect.
6,9,14,23

CHAPTER
6

Put Protection into Action

Your workers deserve
training and protective gear. As an employer, you expect workers to follow
through by using to the fullest the training and protective gear you provide.

The construction
industry has made many strides in protecting its workers from many safety
hazards. Almost everyone agrees it must do more to protect workers from
skin problems. But how can you achieve more protection for your employees?

As an employer, you’ve
shown your interest in progress by looking at this handbook. What more
can you do to protect your workers and to help them protect themselves?

This chapter presents
some additional pointers and resources you can use to help put your concerns
into action.

Choosing And Wearing
Gloves

The main goals for
successful glove wear are:

keep materials
from penetrating or saturating gloves

keep glove insides
clean and dry

To meet these goals,
you must make sure that:

gloves fit

gloves are cleaned
daily

gloves are discarded
when worn out or grossly contaminated

gloves are correct
for the worksite materials

Three types of gloves
are often used for work with wet cement:

impermeable rubber
or butyl

cotton or other
fabric

leather

Some
gloves combine rubber or butyl with cotton, other fabrics, or leather.
Glove thickness and the length of the cuffs vary by task or worker preference.
Fabric or leather gloves are not recommended because they may become saturated
with wet cement.

Without good hygiene,
gloves are no better than no protection at all. If employees can’t
wash with clean water and pH-neutral soap whenever they remove their gloves,
the insides become contaminated. Don’t fool yourself. Gloves on employees
are no proof of protection.
4

Below are the websites
of two well-known glove manufacturers. You can purchase from these and
others through your local safety supply store listed in the business section
of the telephone directory.

Commercial products
are marketed for neutralizing the pH of cement. Mason’s Hand Rinse
is an acidic rinse. Neutralite is a buffering solution. In theory, either
product or other similar products could be helpful if they neutralize
cement on the skin surface.

pH indicator papers
(pH test strips) can be ordered through your local safety supply company
or from Markson LabSales, Inc., at 1-800-528-5114 or Lab Safety Supply
at 1-800-356-0783.

CHAPTER
7

Evaluating Your Success

Let’s say your
company wants to invest time and effort in improving conditions with the
aim of preventing skin problems from cement.

How will you know
if your efforts pay off?

You might say it’s
easy. I’ll see it with my own eyes. It will be plain to everyone.
But that’s probably not true.

Whether your company
employs five cement workers or 500, you can set up a system for measuring
the success of your prevention efforts. This chapter gives some simple
ideas about how to do it.

Compared To What?

When you evaluate
anything, you need a basis for comparison. Two classic methods
are ‘criteria-based’ and ‘norm-based’
comparison.

In school, did your
teacher grade your test by an objective standard and give ‘As’
only for 100%, for example? That’s ‘criteria-based’ evaluation.
Criteria-based means comparing something to an objective standard that’s
set up ahead of time.

If your teacher “graded
on a curve” by comparing you with other students in your class, that’s
‘norm-based’ evaluation. Norm-based means comparing something
with other things in the same category.
To measure your success in reducing skin problems from cement, first choose
your own basis for comparison. Do you want to compare your results with
an objective standard of 100% healthy skin and perfect protective practices?
Or should you measure progress by comparing results with existing conditions?

Measuring Tools
Whichever comparison method you choose, here are some tools you can use
to measure your results. You might also think of other tools.

Observations
and reports of work/personal practices

Symptoms checklist

pH tests of surface
skin

Norm-Based Evaluation

Consider comparing
your workers with themselves before and after beginning your efforts.

Before starting your
efforts, take some baseline measurements. Use written checklists.
Watch your employees work and take reports from them of what they do.
You don’t have to record the employees’ names. You are not comparing
individuals. You are comparing your employees as a groupbefore and after your efforts.

Which best practices
are your employees currently doing? Which are they failing to do? Keep
a written record of your observations. Have your employees complete the
symptoms checklist of the skin problems they currently have. Assure them
their names are not recorded and their answers have no effect on employment.
Ask them to do a pH test of surface skin. Again, this is not a test of
the individual employee. Instead, it is a measure of the success of the
protective practicesyou implement.

Once you have a baseline
record, then begin your effort to reduce skin problems. Instruct employees
in best practices and beegin enforcing these practices on the job.
When you think your efforts may be starting to pay off, go around and
take your measurements again. Now count up the results and compare the
‘BEFORE’ and the ‘AFTER.’ If you or
someone in your company knows how to use a statistical computer program,
you can use it to help your evaluation. Or you can count by hand calculator
and see where there is progress. Keep a record of the outcome.

Take the same measurements
periodically to assess progress. The results can help you adjust your
efforts.

What If Employees
Are Transient?

In construction,
workers come and go. Turnover varies from company to company. Some larger
companies have a steady cadre of core workers and hire or layoff more
as projects demand. Other companies have no steady workers, only transient
ones. This makes evaluation more difficult. But not impossible.

Always keep in mind
that you are not evaluating individual workers. You are evaluating the
success of your efforts by looking at your employees as a group.

If all your workers
are transient and other employers have poor hygiene conditions, you may
not see immediate improvements in the symptoms checklist. But you should
see improvements in the pH tests of surface skin and in compliance with
best protective practices. This should help prevent future dermatitis.

Work With Others

If you work with
other employers and with employees’ unions, you can bring about a
reduction in skin problems in your labor pool.

Working together
and involving your health & welfare plan, you can implement a plan-wide
evaluation. It can look at the reduction in medical costs and worker compensation
disability settlements.
One expert recommendation is to identify one or more health care providers
who are willing to educate themselves about cement dermatitis. Taking
advantage of their expertise can make your efforts more effective.

It is vital that employees believe physicians have their health foremost
in mind. Workers must feel free to seek treatment without fear of impacting
future employment.

CHAPTER
8

Medical Approaches

One attribute of
a good health care provider is a willingness to learn about a new group
of patients. As you begin working with health care providers who will
focus on treating and preventing skin problems among your employees, you
will want to give them appropriate background information. This will be
true whether they are dermatologists, occupational medicine physicians,
or other specialists.

The Physician Alert Brochure is available from CPWR (301-578-8500)
for this purpose. This handbook, including this chapter, also includes
information that may be helpful.

Development of skin
disorders from cement cannot be predicted based on experience. Exposure
may cause irritation or dry skin, ICD, ACD, or burns.

Irritation
or dry skin may include scaling, itchiness, burning, redness. It
may be called xerosis. An employee can move directly from exposure to
irritation or dry skin.

Irritant contact
dermatitis (ICD) can be acute or chronic. It can include stinging,
pain, itching, blisters, dead skin, scabs, scaling, fissures, redness,
swelling, bumps, and dry or watery discharge. Sometimes irritation leads
to infection which leads to ICD. An employee can move straight from
exposure to ICD.

Allergic contact
dermatitis (ACD) includes many symptoms of ICD. ACD is difficult
to cure. It requires continued care and may require change in work.
Reintroduction to exposure poses serious problems. An employee can move
straight from exposure to ACD. This can happen without any warnings,
such as local irritation.

Cement burns
are alkali burns. They can progress and should be referred to the ER
or a burn specialist without delay. By the time an employee becomes
aware of a burn, much damage has already been done and further damage
is difficult to arrest.

PHYSICIAN ALERT

The next three sections
present etiologic agents, surveillance, and intervention/treatment options
which may be helpful to a physician evaluating the skin of a cement products
worker.

ACD. Exam;
stinging; burning; pain; itching; blisters; dead skin; scabs; scaling;
fissures; redness; swelling; bumps, dry or with watery discharge; usually
concentrated where exposure occurs, but also occurs on other body parts;
onset 2 to 7 days or more after exposure. Diagnostic aids: open
application tests; commercially available skin patch tests (e.g., to some
rubber, epoxy, and cement compounds); do not patch test to known irritants;
do not patch test to unknown chemicals.

Visiting the worker’s
worksite or reviewing the Material Safety Data Sheets of products used
there may help to determine what substances the worker is exposed to,
the degree and duration of the exposure, the methods and agents used to
clean the skin, and the type of protective clothing used.

Allergic Contact
Dermatitis (ACD). Chrome allergy is persistent. Trace amounts
of chrome (Cr) are found in many articles of daily life, including food,
water, and cigarettes. Cr may persist in tissues for a long time. A change
of work does not always assure healing of the dermatitis and workers with
mild to moderate dermatitis may be encouraged to remain at work. There
is some evidence that the skin has the ability to reduce Cr6+
to Cr3+ enzymatically.
1,12
It also may be that neutralizing the pH of cement at the skin surface
may convert Cr6+ to Cr3+ . (See reduction of Cr6+
in Scandinavian cement.) For some years, iron sulfate has been added to
cement manufactured in Scandinavia. In one in vivo study, cements with
and without iron sulfate were compared concerning their capacity to elicit
allergic patch-test reactions in eight chromate-hypersensitive individuals.
No patch-test reactions were obtained from a water extract of cement with
iron sulfate when appropriately buffered.
5

Cement Burn.
Following is a typical case history. A young male construction worker
accidentally poured cement over the top of his boots. He was careful to
rinse off all the cement from his boots immediately as advised. Three
hours later, he experienced excruciating pain over the dorsum of his toes
and on removing his boots and wet socks, discovered to his horror that
the dorsum of all his toes had turned a ‘deadly green.' Clinically,
he had full skin thickness burns of the dorsum of all his toes over the
proximal phalanx which subsequently became infected and required hospitalization
and daily dressing for three weeks.
6,9,14,23

The damage from cement
burns may be worsened when a worker applies an emollient such as petroleum
jelly in an attempt to soothe the pain. The emollient occludes the cement
to the skin which increases the burn.

Glossary

acids

A large class of
chemicals with pH values ranging from <7 to <1. Acids with pH 1
are one million times stronger than acids with pH 6.

admixture

Any substance—other
than cement, aggregate, or water—that is mixed with concrete; usually
a chemical solution added to enhance a specific property of the concrete.

alkali

(al-kah-lie)
Any substance which is bitter, irritating, or caustic to the skin, and
has a pH value greater than 7. Strong alkalies are corrosive to skin and
mucous membranes. Portland cement's ingredients make it extremely alkaline.

buffer

A substance that
can neutralize either an acid or an alkali. A buffer is often a weak acid
and so it releases less heat than a strong acid would when neutralizing
an alkali.

caustic

Any strongly alkaline
material which has a corrosive or irritating effect on living tissue.

hexavalent chromium
(Cr6+)

Chromium (Cr) is
a metallic element with three valences: 2, 3, and 6. Elemental and trivalent
(Cr3+) chromium are relatively non-toxic. But hexavalent
(Cr6+) compounds are irritating and corrosive. Cr6+
is more readily absorbed by skin than is Cr3+. Cr6+
is a sensitizing agent. Trace amounts of Cr6+ are in most American
cements as a production contaminant.

hygroscopic

(hi-jrah-skop-ik)
Having a strong tendency to absorb water, which results in swelling. Cement
is hygroscopic. It absorbs moisture from skin, drying it.

logarithmic scale

On a logarithmic
scale, the intervals between numbers are not equal or linear. Instead,
each number represents a value that is many times greater or smaller than
the previous number. The pH scale and the Richter scale for earthquakes
are logarithmic.

neutralize

To make chemically
neutral or balanced. An alkali can be neutralized by adding an acid, and
vice versa. Also see: buffer.

occlude/occlusion

(a-klood/a-kloo-zhun)
To seal a material in contact with the skin surface. To take in and retain
a substance on the interior rather than the exterior surface.

pH

pH is a value representing
the acidity or alkalinity of a watery solution on a logarithmic scale.
Pure water is the standard used in arriving at this value. Pure water
is pH 7. pH 1 is extremely acidic. pH 13 is extremely alkaline. pH 13
is one million times more alkaline than pure water. pH 1 is one million
times more acidic than pure water.

sensitizer

A material which
can produce a pathological immune response. An allergen. Hexavalent chromium
(Cr 6+ ) is a sensitizer or sensitizing agent. Once sensitized, further
contact must be avoided.